British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019

Available Online at http://www.bjpmr.org BRITISH JOURNAL OF PHARMACEUTICAL AND MEDICAL RESEARCH

Review ISSN:2456-9836 ICV: 60.37 Article

Murat Eren Özen, Murat Aydin

Olfactory Reference Syndrome: A Separate Disorder Or Part Of A Spectrum

1Psychiatrist, Department of Psychiatry, Private Adana Hospital, Adana Büyük şehir Belediyesi kar şısı, No:23, Seyhan-Adana- Türkiye. 2Private Dental Clinics, Gazipa şa bulv. Emre apt n:6 (kitapsan kar şısı) k:2 d:5 Adana- Türkiye. http://drmurataydin.com

ARTICLE INFO ABSTRACT

This article provides a narrative review of the literature on olfactory reference syndrome Article History: Received on (ORS) to address issues focusing on its clinical features. Similarities and/or differences with other psychiatric disorders such as obsessive-compulsive spectrum disorders, social anxiety 10 th Jan, 2019 Peer Reviewed disorder (including a cultural syndrome; taijin kyofusho), somatoform disorders and hypochondriasis, delusional disorder are discussed. ORS is related to a symptom of taijin on 24 th Jan, 2019 Revised kyofusho (e.g. jikoshu-kyofu variant of taijin kyofusho) Although recognition of this syndromes more than a century provide consistent descriptions of its clinical features, the on 17 th Feb, 2019 Published limited data on this topic make it difficult to form a specific diagnostic criteria. The core on 24 th Feb, symptom of the patients with ORS is preoccupation with the belief that one emits a foul or 2019 offensive body odor, which is not perceived by others. Studies on ORS reveal some limitations. Although there is a lack of data for validators, including symptom profile; familial aggregation; environmental risk factors; cognitive, emotional, temperament and personality Keywords: correlates; biological markers; patterns of comorbidity; course of illness: and response to Other Specified treatment, current data suggest that ORS appears different form other disorders, but, this Obsessive- Compulsive And difference is not enough to put this syndrome in a separate diagnosis., in DSM-5, ORS has its Related Disorder, place in the "Other Specified Obsessive- Compulsive or Related Disorder" category, in which, Obsessive- this category is for patients who have symptoms characteristic for obsessive-compulsive and Compulsive Spectrum Disorder, Imagined related disorder but do not meet the full criteria for any specific obsessive-compulsive or Body Odor related disorder. Further studies are needed for understanding the nature, prognosis, treatment and morbidity.

Br J Phar Med Res Copyright©2019, Murat Eren Özen et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

Corresponding Author: Murat Eren Özen, M.D., Psychiatrist, Department of Psychiatry, Private Adana Hospital, Adana Büyük şehir Belediyesi kar şısı, No:23, Seyhan -ADANA - Türkiye 1617

British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019

INTRODUCTION: Olfactory reference syndrome (ORS) is a ORS descriptions has been mentioned in previous condition in which individuals erroneously believe publications since the late 1800s (Potts CS, 1891) that they emit an unpleasant, foul, or offensive (Tilley H, 1895) (Bromberg W, 1934) (Harriman body odor. Odors may include almost anything PL, 1934)(Alvarez WC, 1959) (Philips KA, 2006) foul smelling and are often believed to originate (Philips KA, 2007). More than a hundred cases of from an organ or system, including the mouth, ORS have been reported. In the literature, cases genitals, rectum, or skin (APA, 2000). In clinical consistent with this syndrome appear between settings, common specific concerns include 1891 and 1966. Somehow, although the clinical halitosis, genital odor, sweat, flatulence or anal descriptions did not contain signs and symptoms odor (Philips KA et al., 2006). Uncommonly, sufficient to meet any of the psychiatric criteria, patients have concerns on emitting non-bodily reported cases with symptoms of ORS were odors such as ammonia (Tilley H, 1895), detergent described as schizophrenia. Pryse-Phillips, only in (Ross CA, 1987), burned rags (Harriman, 1934), 1971, defined the term olfactory reference or rotten onions (Sutton, 1919). Usually, the belief syndrome as a separate group with consistent of emitting an odor is often accompanied by ideas phenomenology, after characterizing a large case or delusions that the odor is noticeable to other series and carefully considering the differential people and they will react negatively, for example, diagnosis (Pryse-Philips W, 1971). As ORS by rubbing their nose in reference to the odor or involves a single delusional belief, it has also been turn away in disgust. Repetitive behaviors of referred to a type of monosymptomatic smelling themselves, showering excessively and hypochondriacal psychosis (Bishop ER, 1980) attempting to mask the odor are performed by (Beary MD, 1981) (Munro A, 1988) (Osman AA, many patients (Pyrse-Philips, 1971). 1991) (Ulzen TPM, 1993). History

Fig.1: Olfactory reference syndrome has some specific symptoms for obsessive compulsive and related disorders but does not meet full criteria for any disorder in DSM-V

ORS through DSM and ICD Classifications International Classification of Disease (ICD), the In both the Diagnostic and Statistical Manual of term ORS is not mentioned or included as a Mental Disorders, 4th. Edition (DSM-IV) and the separate disorder, However, ORS symptoms are

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British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019 considered as delusional disorder, somatic type in Clinical Features of ORS DSM IV (Potts CS, 1891); “Somatic delusions can Perceived Odors occur in several forms. Most common are the Unpleasant, foul or offensive body odors include person’s conviction that he or she emits a foul odor almost anything bad smelling and are often from the skin, mouth, rectum, or vagina….”(Potts believed to originate from an organ or the system CS, 1891). Similarly, ICD-10’s text on persistent (APA, 2000). Consistent with prior reports, ORS delusional disorders notes that delusions may patients most commonly focus on bodily smells, “express a conviction that…others think that he or such as general body odor, halitosis, genital odor she smells….”(Philips KA, 2007). In DSM-IV, and flatulence/fecal/anal odor. All subjects report ORS is also referred to as a type or part of social at least one odor that may normally be emitted anxiety disorder (social phobia), noting that from their bodies (Pryse-Philips W, 1971)(Iwu persons with social phobia may fear to offend with CO, 1990)(Osman AA, 1991)(Philips KA,2006) their body odor. Under the Cultural note for ORS (Begum M, 2010). Rarely, some patients reported in DSM-IV : “taijin kyofusho” . urine, sperm, sweat, armpit odor or malodorous “In certain cultures (e.g., Japan and Korea), from hands and feet (Tee CK, 2014)(Pryse-Philips individuals with Social Phobia may develop W, 1971)(Iwu CO, 1990)(Osman AA, 1991). persistent and excessive fears of giving offense to Occasional odors that patients reported are said to others in social situations…. These fears may take resemble non-bodily smells, such as ammonia, the form of extreme anxiety that blushing, eye-to- detergent, burned rags, candles or rotten onions eye contact, or one’s body odor will be offensive (Tilley H, 1895) (Sutton RL, 1919)(Harriman PL, to others. Taijin kyofusho , is similar to social 1934)(Ross CA,1987) (Begum M, 2010). Emitting phobia in Japan and Korea (Suzuki K, 2004). body odor that may smell like rotting fish is Although its clinical features are confusingly reported by the patients with an uncommon mentioned in three different sections of DSM-IV, metabolic disorder, which is also known as fish where they even are not adequately described, for malodor syndrome: trimethylaminuria (Mitchell more than a century, ORS has been stated as a SC, 2001). discrete syndrome in many cultures. However, Odor Hypersensitivity or Misinterpretation given the suffering and impairment associated Patients with temporal lobe epilepsy may have with it, the term ORS (currently the most widely complaints of smelling foul odors. Olfactory used term for this syndrome) is still not explicitly sensations caused by pituitary tumors may irritate mentioned.The questions whether ORS should be the hippocampus locally, so that foul odors mentioned as a part of other disorder such as “araise”. ORS symptoms differ from symptoms of delusional disorder or social phobia, or should be other disorders that may cause olfactory taken as a separate diagnosis with its own set of hallucinations, including migraine headaches, diagnostic criteria, remain unclear. head injury, intranasal disorders, consisting of a Statements on ORS through DSM and ICD typical bodily odor that emanates from the DSM-III-R: “Convictions that the person emits a sufferer; being persistent rather than brief and not foul odor…are one of the most common types of being accompanied by other auras, typical of delusional disorder, somatic type” (APA, 1987). temporal lobe epilepsy (APA-2014) (Pryse- DSM-IV: “Somatic delusions can occur in several Philips W, 1971) (Acharya V, 1998)(Chen C, forms. Most common are the persons’ conviction 2003). On the other hand, frontal, ethmoidal or that he or she emits a foul odor from the skin, sphenodial sinus inflammations can be causes of mouth, rectum or vagina….” (APA, 2000). subjective sense of offensive odors. Olfactory ICD-10: “Express a conviction that… others think reference syndrome is characterized by the false that he or she smells….” (WHO, 1992). belief of patients that he or she has a foul body odor that is not actually perceived by others. The

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British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019 idea is purely based on their misinterpretation of perceive. However, some ORS repetitive behaviors other people’s behavior (e.g. opening windows or appear unique to ORS; for example, neither BDD nor nose rubbing) (APA, 2014) (Alvarez WC, OCD involve sniffing ones’ underwear, excessively 1958)(Marks IM, 1988)(Iwu CO, 1990). However, laundering ones’ clothes or camouflaging their with a recent study suggests that it is unclear whether mints. In a recent study, nearly all subjects (95%) were such patients are hypersensitive to normal body found to perform at least one excessive repetitive odors (which they consider noxious or offensive) behavior. Moreover, camouflaging behavior was or whether they experience an olfactory found in all patients with ORS? (Philips KA, 2011). hallucination (Philips KA, 2011). Insight Referential Thinking The ORS patient may have good, fair, poor or In ORS patients, referential thinking involves absent insight into the behavior (APA, 2014). misinterpreting the meaning of other people’s Previous findings suggest that most of the patients comments (e.g. about an odor), gestures (e.g. have delusional beliefs. while some of the patients touching their nose), or other behaviors (e.g. have poor insight. However, no prior study clearing their throat, opening a window, or looking assessed insight in ORS using a reliable and valid or moving away from the patient) (Phillips KA, measurement (Bishop ER, 1980) (Malasi TH, 2006). Nearly all subjects (88%) in a recent study 1990)(Osman AA, 1991)(Suzuki K, 2004) reported lifetime ideas or delusions of reference (Begum M, 2010)(Philips KA). In addition, only (Philips KA, 2011). These findings 21% of patients with delusional beliefs are are compatible with Pryse-Phillips’ finding in the reported (Prazeres AM, 2010), and findings early seventies (97%) (Pryse-Phillips W, 1971). suggest that although ORS beliefs are often Repetitive Behaviors delusional, ORS should not be classified as Preoccupation of patients leads to repetitive behaviors, delusional disorder (Philips KA, 2011). such as washing the body or changing clothes (APA, Age at Onset, Chronicity and Gender Differences 2014). The content of some ORS behaviors is also Literature reports indicate the mean age of ORS similar to that of compulsions that may occur in Body onset is in the early or mid twenties (Phillips KA, Dismorphic Disorder (BDD) and/or Obsessive 2006) (Begum M2010), but the text accepts the Compulsive Disorder (OCD) - e.g. repetitive mean age at onset of 25 years of age (APA, 2014). checking, excessive showering and excessive clothes Most reports found that ORS symptoms were changing. Similar in form to those of OCD and BDD, usually chronic (Pryse-Phillips W, 1971)(Philips excessive repetitive behaviors of ORS patients are KA, 2011). Follow-up of patients over two years performed and intended to eliminate, check, obtain demonstrated no changes in the symptoms (Pryse- reassurance about or mask the perceived odor (i.e. Phillips W, 1971). The syndrome is predominant camouflaging) (Prazeres AM, 2010). They spend time in males and in singles (APA, 2014) with thoughts about their odor and engaging behaviors Functioning/Disability to check or minimize. These behaviors are usually to Data indicate that ORS causes clinically check or eliminate odor that is perceived, to obtain significant limitations in functioning, distress and reassurance about it, and to prevent others from significant social disability (Pryse-Phillips W, smelling it. Checking their body for odor; excessive 1971). Strikingly, rate of socially active patients showering or other washing; or repetitive use of with ORS is very low. Many individuals are deodorant, mouthwash, or perfume are some examples socially isolated (Pryse-Phillips W, 1971). Shame, for patients with ORS (Pryse-Phillips W, 1971) embarrassment, and/or concern about offending (Bishop ER, 1980) (Marks I , 1988) (Malasi TH, others with their odor causes prominent social 1990). Repetitive behaviors are the result of shame avoidance, isolation and impairment of work or and embarrassment, referential thinking and time school functioning (Pryse-Phillips W, consuming preoccupations to eliminate the odor they 1971)(Bishop ER, 1980)(Davidson M,

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1982)(Malasi TH, 1990). They spend a lot of time proctologists, surgeons, and gastroenterologists with the thoughts about their odor and their for supposed anal odors; and other physicians such behaviors to check or minimize it. Shame and as dermatologists and gynecologists without embarrassment, referential thinking, time- effective results (Phillips KA, 2006; Prazeres AM, consuming preoccupations and repetitive 2010). Non-psychiatric consultations and/or behaviors are the main causes of patients’ treatments appear usually ineffective and are disability to hold a job, attend school or be in therefore associated with patient dissatisfaction public places (Alvarez WC, 1958)(Pryse-Phillips (Forte FS, 1952) (Pryse-Phillips W, 1971) (Iwu W, 1971)(Bishop ER, 1980)(Brotman AW, 1984) CO, 1990) (Prazeres AM, 2010). (Marks IM, 1987) (Iwu CO, 1990) (Phillips KA, Treatment Results 2006). Psychotropic medications are used by many Comorbidity patients but it is not clear whether these drugs are Comorbidity of other mental disorders with ORS used for ORS or for the comorbid disorders is reported. Major depressive disorder (MDD) was (Philips KA, 2011). Case series and anecdotal the most commonly s reported as secondary to reports suggest that serotonin-reuptake inhibitor ORS, (Phillips KA, 2006)(Prazeres AM, 2010). In (SRI) monotherapy, or combination with a study, nearly three quarters of the sample was antipsychotics, or an antipsychotic monotherapy considered to have depressive symptoms primarily may all be effective treatments (Beary MD, 1981) due to ORS (Philips KA, 2011). Lifetime (Marks I, 1988) (Malasi TH, 1990) (Osman AA, substance use disorder is found in nearly half of 1991) (Gomez-Perez JD, 1994) (Dominguez RA, the patients. Social anxiety disorder, OCD and 1997) (Stein DJ, 1998) (Kobayashi T, 2005) BDD were also encountered frequently. Although (Phillips KA, 2006) (Feusner JD, 2010) (Prazeres ORS seems to have important differences, high AM, 2010). However, although ORS beliefs are comorbidity with these disorders questions often delusional, treatments with SRIs were found whether ORS is related with them (Stein DJ, more efficacious than with antipsychotics (Phillips 1998)(Lochner C, 2003)(Phillips KA, KA, 2006) (Begum M, 2010) (Philips KA, 2011). 2006)(Feusner JD, 2010). Limited data show that behavioral approaches, Suicidality consisting of exposure to avoided social situations In a study by Pryse-Phillips’ on 36 subjects, 43% and ritual prevention, may be efficacious as well experienced “suicidal ideas or action” and 5.6% (Phillips KA, 2006) (Begum M, 2010). However, committed suicide during the follow-up period. treatment research is extremely limited for ORS The author states that the suicides were (Philips KA, 2011). attributable to ORS (Pryse-Phillips W, 1971). Relation with Obsessive-Compulsive Spectrum Additionally, the literature does not provide any Disorders evidence or suggestion that ORS is a result of Although ORS may be related to one or more of common stressors or losses, or a culturally the disorders mentioned, in DSM, it is proposed to sanctioned response to a significant/particular be an obsessive-compulsive spectrum or an event. Lifetime suicidal ideation and suicidal anxiety disorder. However, lack of quality attempts are reported very high among ORS research and the inexistence of direct comparison patients (Prazeres AM, 2010). studies between ORS and obsessive-compulsive Treatment Seeking by Patients spectrum disorders, makes this disorder to be Non-psychiatric, medical, surgical or dental unique in DSM (Philips KA, 2011). treatments are ineffective in all cases of ORS Conflicts patients (Philips KA, 2011). As reported in the In many cases, the response to psychotropic agents literature, patients consult dentists, surgeons, and or to behavioral therapy suggest that ORS has ear-nose-throat specialists for supposed halitosis; many features of an internalizing disorder, rather

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British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019 than reflecting a social deviance or conflict. But in with ORS perform excessive, repetitive behaviors the literature, this exact evidence or suggestion is that are compulsive, which is apparently different not pointed out as a result of social deviance, other from patients with social anxiety disorder. These conflicts with society. behaviors are usually to check or eliminate odor Awareness that perceived, to obtain reassurance about it, and Many patients with ORS do not seek psychiatric to prevent others from smelling it. treatment at all, which may be due to the lack of Obsessive Compulsive Disorder public awareness that these symptoms represent a The repetitve behaviors observed in cases of ORS treatable entity. Usually, ORS patients visit non- raised question whether ORS is related to mental health professionals such as dentists, Obsessive Compulsive Disorder (OCD). gastroenterologists, dermatologists, or Individuals with ORS usually report repetitive, gynecologists, who may not be aware that ORS is troubling and intrusive thoughts about their a known form of mental illness. But also in “odor,” which some describe as obsessive psychiatric settings, many patients with ORS (Alvarez, 1958) (Hawkins C, 1987) (Osman AA, receive no diagnosis or an inaccurate diagnosis or 1991). Similar with OCD patients, ORS patients even misidentification may occur. may spend many hours per day being preoccupied Differential Diagnosis: Similarities and with these thoughts (Hawkins C, 1987). Other than Boundaries with Other Psychiatric Disorders that, the Serotonergic drug response of ORS Social Anxiety Disorder patients is an additional similarity with OCD Some clinical features of ORS seem to be common (Dominguez RA, 1997) (Stein DJ, 1998) (Lochner with social anxiety disorders. In Japan and Korea, C, 2001). However, in contrast to ORS, presence ORS is considered to be a form of taijin kyofusho , of delusional belief is less common in OCD (Insel which is a culturally bounded syndrome. TR, 1986) (Kozak MJ, 1994) (Eisen JL, 1999). Individuals with taijin kyofusho fear that their Body Dysmorphic Disorder body or bodily functions embarrass, displease or ORS’s clinical features have many similarities to be offensive to others; in terms of facial body dysmorphic disorder (BDD); the primary expressions, odor, appearance, or movements symptoms of both disorders involve a belief of a (APA, 2000). One of the several fears of bodily defect which leads to anxious avoidance of individuals with taijin kyofusho is emitting body relevant (often social) situations (Lochner C, odor (17%) (Matsunaga H, 2001). Most 2003). Preoccupation and repetitive behaviors to individuals with ORS are concerned about the check or remediate the perceived problem are social implications of emitting a foul odor, with other similarities (Bishop ER, 1980) (Beary MD, patients commonly experiencing shame, 1981) (Davidson M, 1982) (Brotman AW, 1984) embarrassment, and anxiety in social situations, as (Marks I, 1988) (Phillips KA, 2006).Both ORS well as avoidance of social situations (Bourgeois and BDD are characterized by frequent seeking of M, 1972) (Lochner C, 2003). Comparison of medical treatment in an attempt to alleviate the individuals with ORS to those with social anxiety symptoms (e.g. treatment from dentists or disorder found similarities in demographics and gastroenterologists in ORS, surgery or also a comorbidity with depression. However, the dermatologic treatment in BDD) (Bishop ER, key characteristic of social anxiety disorder is 1980) (Davidson M, 1982) (Iwu CO, 1990) rather different: patients with social anxiety (Malasi TH, 1990) (Osman AA, 1991). disorder have fear that they will act in a way that Somatoform Disorders and Hypochondriasis will be embarrassing or humiliating. Thus, social There are also some apparent similarities to other anxiety patients are typically primarily concern somatoform disorders, primarily to about their actions or how they speak, eat or write hypochondriasis. Although both disorders involve etc., rather than how they smell. Most individuals preoccupation with the body, they are often

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British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019 marked by obsessional thinking and include with obsessive-compulsive and related disorder- repetitive behaviors such as checking and seeking specific symptoms, but who do not fully meet the medical diagnoses and treatments (APA, 2000). In criteria for any specific obsessive-compulsive or hypochondriasis, the core symptom is the fear related disorder. about having a serious disease, whereas in ORS, This diagnosis is appropriate under three ideas or delusions of reference and social situations: (1) an atypical presentation, (2) another avoidance characteristically are prominent. specific syndrome not listed in DSM-5, or (3) the Delusional Disorder information presented is insufficient to make a full Reports suggest that beliefs in ORS may not diagnosis of an obsessive-compulsive or related always be delusional and in such cases does not disorder. In assessing a patient with olfactory meet the criteria for delusional disorders. In reference syndrome, it is important to exclude addition, reports of pharmacotherapy treatment somatic causes. (APA, 2014) responses make ORS different from a delusional In the psychiatric literature, ORS has been disorder. Some reports describe described in multiple regions of the world and it improvement/response to antipsychotics (Riding has long been recognized as a discrete syndrome J, 1975) (Osman AA, 1991), while some show that occurs in individuals. Data indicate that ORS response to serotonin reuptake inhibitor (SRI) causes significant limitations in functioning or (Stein DJ, 1998) (Lochner C, 2003) (Kobayashi T, distress and significant social disability (Pryse- 2005). Others seem to respond to tricyclic Phillips W, 1971). Although the exact underlying antidepressants (TCA) (Brotman AW, 1984) mechanism of ORS is unclear, preliminary (Fernando N, 1988), or to combinations (Malasi (uncontrolled) reports of improvement in ORS TH, 1990) (Osman AA, 1991) (Luckhaus C, with pharmacotherapy or psychosocial treatment 2003). Depressive episodes, with or after ORS, are (behavioral therapy - Marks I, 1988; cognitive- more common than in delusional disorders. behavioral therapy - Bizamcer AN, 2008; Patients with ORS often have prolonged paradoxical intention - Milan MA, 1982) indicate depressive episodes (Pryse-Phillips W, 1971) indirect results of support to the existence of (Malasi TH, 1990). Depressive episodes are often disturbances and psychobiological processes in considered secondary to ORS. In the majority of ORS. cases, these episodes appear after the development As seen in the literature, studies on ORS reveal of odor concerns (Pryse-Phillips W, 1971). some limitations, including relatively small In a study to assess delusionality or insight of ORS sample groups, lack of control-comparison beliefs, most of ORS (84.6%) patients had groups, non-psychiatric medical reports, medical delusional ORS beliefs, less (15.4%) had non- conditions, seizure histories, efficacy of delusional beliefs (Philips KA, 2011). The belief psychotropic medications on ORS and each of the of a subjective sense of smell that does not exist ORS symptoms, use of standardized measures. externally may rise to the level of a somatic Further studies are needed for understanding the delusion, in which case a diagnosis of delusional nature, prognosis, treatment and morbidity. disorder should be considered. The syndrome has For validators, there is a lack of data containing been well documented in the psychiatric literature, the symptom profile; family union; environmental usually classified as a delusion of perception. risk factors; cognitive, emotional, temperament Whether or not it deserves a special diagnostic and personality relations; biological markers; category is open to question (APA, 2014). patterns of comorbidity; The course of the disease: CONCLUSION and in response to treatment, available data Finally, in DSM-5 so far, ORS has been included indicate that ORS appears to be different from in the Other Obsessive-Compulsive or Related other disorders such as social anxiety disorder, Disorder category. This category is for patients BDD, OCD, hypochondriasis or delusional

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British Journal of Pharmaceutical and Medical Research Vol.04, Issue 01, Pg.1617-1625, January-February 2019 disorder. Differences in terms of symptom profile, 14) Munro A. Monosymptomatic hypochondriacal comorbidity, and response to treatment can be psychosis. Br J Psychiatry 1988;153:37–40. identified. 15) Osman AA. Monosymptomatic hypochondriacal REFERENCES psychosis in developing countries. Br J 1) American Psychiatric Association-APA. Psychiatry. 1991;159:428–431. Diagnostic and Statistical Manual of Mental 16) Ulzen TPM. Pimozide-responsive Disorders. 4th ed. Washington, DC: American monosymptomatic hypochondriacal psychosis in Psychiatric Association; 2000. an adolescent. Can J Psychiatry. 1993;38. 2) Phillips KA, Gunderson C, Gruber U. Delusions 17) Suzuki K, Takei N, Iwata Y, Sekine Y, Toyoda T, of body malodour the olfactory reference Nakamura K, Minabe Y, Kawai M, Iyo M, Mori syndrome. In: Brewer W, Castle D, Pantelis C, N. Do olfactory reference syndrome and jiko-shu- editors. Olfaction and the Brain. New York: kyofu (a subtype of taijin-kyofu) share a common Cambridge University Press; 2006. pp. 334–353. entity? Acta Psychiatr Scand. 2004;109:150–155. 3) Tilley H. Three cases of parosmia: causes and 18) American Psychiatric Association-APA. treatment. Lancet. 1895:907–908. Diagnostic and Statistical Manual of Mental 4) Ross CA, Siddiqui AR, Matas M. DSM-III: Disorders. Third Edition. Washington, D.C.: Problems in diagnosis of paranoia and obsessive- APA; 1987. compulsive disorder. Can J Psychiatry 19) World Health Organization-WHO. Geneva: 1992. 1987;32:146-148. The ICD-10 Classification of Mental and 5) Harriman PL. A case of olfactory hallucination in Behavioural Disorders. a hypochondriacal prisoner. Journal of Abnormal 20) Iwu CO, Akpata O. Delusional halitosis. Review Social Psychology 1934;29:457–458. of the literature and analysis of 32 cases. Br Dent 6) Sutton RL. Bromidrosiphobia. JAMA J 1990;168:294–296. 1919;72:1267-1268. 21) Begum M, McKenna PJ. Olfactory reference 7) Potts CS. Two cases of hallucination of smell. syndrome: a systematic review of the world University of Pennsylvania Medical Magazine literature. Psychol Med 2010:1–9. 1891:226. 22) Tee CK, Suzaily W. Unremitting body odour: A 8) Bromberg W, Schilder P. Olfactory imaginations case of Olfactory Reference Syndrome. La Clinica and olfactory hallucinations. A.M.A. Archives of terapeutica, 2014, 166(2), 72-73. Neurology and Psychiatry 1934;32:467–492. 23) Mitchell SC, Smith RL. Trimethylaminuria: the 9) Alvarez WC. Practical leads to puzzling fish malodor syndrome. Drug Metab Dispos diagnoses. Journal of Medical Education 2001;29:517–521. 1959;34:448–448. 24) American Psychiatric Association-APA. 10) Phillips KA, Castle D. How to Help Patients with Diagnostic and Statistical Manual of Mental Olfactory Reference Syndrome. Current Disorders. 5th ed. Washington, DC: American Psychiatry 2007;6:49–65. Psychiatric Association; 2014. 11) Pryse-Phillips W. An olfactory reference 25) Acharya V, Acharya J, Luders H. Olfactory syndrome. Acta Psychiatr Scand 1971;47:484– epileptic auras. Neurology 1998;51:56–61. 509. 26) Chen C, Shih YH, Yen DJ, Lirng JF, Guo YC, Yu 12) Bishop ER. An olfactory reference syndrome - HY, Yiu CH. Olfactory auras in patients with monosymptomatic hypochondriasis. J Clin temporal lobe epilepsy. Epilepsia 2003;44:257– Psychiatry 1980;41:57–59. 260. 13) Beary MD, Cobb JP. Solitary psychosis--three 27) Marks I. Fears, Phobias, and Rituals. Oxford: cases of monosymptomatic delusion of alimentary Oxford University Press; 1987. stench treated with behavioural psychotherapy. Br 28) Prazeres AM, Fontenelle LF, Mendlowicz MV, de J Psychiatry 1981;138:64–66. Mathis MA, Ferrão YA, de Brito NF, Diniz JB,

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Gonzalez CH, Quarantini LC, Marrocos RP, 40) Kobayashi T, Kato S. Senile depression with Miguel EC. Olfactory reference syndrome as a olfactory reference syndrome: A subtype of body dysmorphic disorder. J Clin psychopathological review. Psychogeriatrics Psychiatry 2010;71:87–89 2005;5:55–63. 29) Marks I, Mishan J. Dysmorphophobic avoidance 41) Matsunaga H, Kiriike N, Matsui T, Iwasaki Y, with disturbed bodily perception: a pilot study of Stein DJ. Taijin kyofusho: a form of social anxiety exposure therapy. Br J Psychiatry 1988;152:674– disorder that responds to serotonin reuptake 678. inhibitors? Int J Neuropsychopharmacol 30) Malasi TH, el-Hilu SM, Mirza IA, el-Islam MF. 2001;4:231–237. Olfactory delusional syndrome with various 42) Bourgeois M, Paty J. Autodysosmophobia and the aetiologies. Br J Psychiatry 1990;156:256–260. psychopathology of smell (a propos of 7 cases). 31) Philips KA, Menard W. Olfactory Reference Bord Med 1972;5:2269–2286 Syndrome: Demographic and Clinical Features of 43) Lochner C, Stein DJ. Olfactory reference Imagined Body Odor. Gen Hosp Psychiatry syndrome: diagnostic criteria and differential 2011;33(4): 398-406. diagnosis. J Postgrad Med 2003; 49:328–331. 32) Davidson M, Mukherjee S. Progression of 44) Hawkins C. Real and imaginary halitosis. BMJ olfactory reference syndrome to mania: a case 1987;294:200–201. report. Am J Psychiatry. 1982;139:1623–1624. 45) Insel TR, Akiskal HS. Obsessive-compulsive 33) Brotman AW, Jenike MA. Monosymptomatic disorder with psychotic features - a hypochondriasis treated with tricyclic phenomenological analysis. Am J Psychiatry antidepressants. Am J Psychiatry 1984;141:1608– 1986;143:1527–1533. 1609. 46) Kozak MJ, Foa EB. Obsessions, overvalued ideas, 34) Stein DJ, Le Roux L, Bouwer C, van Heerden B. and delusions in obsessive-compulsive disorder. Is olfactory reference syndrome an obsessive- Behav Res Ther 1994;32:343–353. compulsive spectrum disorder?: two cases and a 47) Eisen JL, Phillips KA, Rasmussen SA. Obsessions discussion. J Neuropsychiatry Clin Neurosci and delusions: the relationship between obsessive 1998;10:96–99. compulsive disorder and the psychotic disorders. 35) Lochner C, Vythilingum B, Stein DJ. Olfactory Psychiatric Annals 1999;29:515–522. reference syndrome: diagnostic criteria and 48) Riding J, Munro A. Pimozide in the treatment of differential diagnosis. Primary Care Psychiatry monosymptomatic hypochondriachal psychosis. 2001;7:55–59. Acta Psychiatr Scand. 1975;52:23–30. 36) Feusner JD, Phillips KA, Stein DJ. Olfactory 49) Fernando N. Monosymptomatic hypochondriasis reference syndrome: issues for DSM-V. Depress treated with a tricyclic antidepressant. Br J Anxiety 2010;27:592–599. Psychiatry 1988;152:851–852. 37) Forte FS. Olfactory hallucinations as a proctologic 50) Luckhaus C, Jacob C, Zielasek J, Sand P. manifestation of early schizophrenia. Am J Surg Olfactory reference syndrome manifests in a 1952;84:620–622. variety of psychiatric disorders. International 38) Gomez-Perez JD, Marks IM, Gutierrez-Fisac JL. Journal of Psychiatry in Clinical Practice Dysmorphophobia: clinical features and outcome 2003;7:41–44. with behavior therapy. Eur Psychiatry 51) Bizamcer AN, Dubin WR, Hayburn B. Olfactory 1994;9:229–235. reference syndrome. Psychosomatics 39) Dominguez RA, Puig A. Olfactory reference 2008;49:77–81. syndrome responds to clomipramine but not 52) Milan MA, Kolko DJ. Paradoxical intention in the fluoxetine: a case report. J Clin Psychiatry treatment of obsessional flatulence ruminations. J 1997;58:497–498. Behav Ther Exp Psychiatry. 1982;13:167–172.

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How To Cite This Article: Murat Eren Özen, Murat Aydin Olfactory Reference Syndrome: A Separate Disorder Or Part Of A Spectrum Br J Pharm Med Res , Vol.04, Issue 01, Pg.1617-1625, January - February 2019. ISSN:2456-9836 Cross Ref DOI : https://doi.org/10.24942/bjpmr.2019.445 Source of Support: Nil Conflict of Interest: None declared

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